Best Isolation Practices in Nursing Homes During Norovirus Outbreaks
Immediately isolate all symptomatic residents in their rooms with dedicated nursing staff, exclude ill staff for 48-72 hours after symptom resolution, and consider isolating both exposed and unexposed well residents to break transmission cycles—these measures are most effective when implemented within 3 days of the first case. 1, 2, 3
Core Isolation Strategy
Symptomatic Resident Management
- Cohort all ill residents together in a designated unit or area with dedicated nursing staff who care exclusively for infected persons 1, 2
- Maintain isolation until 24-48 hours after complete symptom resolution 1, 2
- Do not transfer ill residents to unaffected units or other facilities except for medical necessity and only after consultation with infection control staff 1
Proactive Isolation of Well Residents
- Consider isolating both exposed AND unexposed well residents during outbreaks in nursing homes to break the transmission cycle and prevent additional cases—this is a unique recommendation specific to long-term care facilities 1, 2
- Restrict exposed asymptomatic residents from moving to unaffected areas for 48 hours after exposure 1, 2
Staff Management
Exclusion Protocols
- Exclude all symptomatic staff during illness and for 48-72 hours following complete resolution of symptoms 1, 2
- Prevent exposed asymptomatic staff from working in unaffected areas for 48 hours after exposure 1, 2
- Do NOT require negative stool results before staff return to work 1, 2
Critical Timing
- Implement all control measures within 3 days of the first case onset—this timing is crucial for effectiveness in reducing illness among both staff and residents 3
Visitor and Admission Restrictions
- Screen all visitors for symptoms and exclude symptomatic individuals 1
- At minimum, caution all visitors about risks and emphasize hand hygiene with soap and water (not hand sanitizer) 1
- Close affected units to new admissions to prevent introduction of new susceptible residents 1
Environmental Control
Disinfection Protocol
- Use sodium hypochlorite (chlorine bleach) solution at 1,000-5,000 ppm concentration (5-25 tablespoons of 5.25% household bleach per gallon of water) on all hard, nonporous surfaces 1, 2
- Prepare bleach solutions fresh daily for use within 2 hours due to evaporative dilution 1
- Focus intensive cleaning on bathrooms and high-touch surfaces including door knobs, hand rails, bed rails, and call buttons 1, 2
- Avoid phenolic compounds, triclosan, and quaternary ammonium compounds as they are less effective against norovirus 1
Hand Hygiene Requirements
- Mandate handwashing with soap and running water for at least 20 seconds—alcohol-based hand sanitizers have limited efficacy against norovirus and should NOT substitute for soap and water 1, 2, 4
- Alcohol-based sanitizers (≥70% ethanol) may serve only as an adjunct between proper handwashings 2, 4
Critical Pitfalls to Avoid
- Do not rely on alcohol-based hand sanitizers as primary hand hygiene—norovirus is a non-enveloped virus resistant to alcohol 1, 2, 4
- Do not delay isolation measures—effectiveness drops significantly after 3 days from first case 3
- Do not transfer residents between units during outbreaks, as single index cases are associated with higher attack rates (57.5% of outbreaks start this way) 5
- Avoid exposure to vomit and implement immediate protocols when vomiting occurs, as aerosolized particles are a major transmission route 5, 6
Special Considerations for Nursing Homes
High-Risk Population Impact
- Recognize that nursing home residents have higher hospitalization rates (10.2%) and case-fatality rates (2.0-2.5%) compared to healthy adults 4, 7
- Prolonged illness courses of 4-6 days are common in elderly residents 8
- Person-to-person transmission is the predominant mode in nursing homes (not foodborne), often through bedside care activities 5, 7